Pilot Implementation of a Nutrition-Focused Community-Health-Worker Intervention among Formerly Chronically Homeless Adults in Permanent Supportive Housing

3.4. Individual Level CHW Intervention

The lack of necessary kitchenware was addressed through the creation of an Amazon Wish List by leadership at the faith-based partner organization in order for church members to purchase kitchenware items on the wish list to be distributed by the CHWs. As the project progressed, grant money was repurposed to purchase the necessary kitchenware not fulfilled through the wish list for all 83 residents completing the needs assessment. CHWs received feedback from residents with dental issues who reported benefiting from receiving blenders to make their food easier to eat. Cooking safety was increased by providing air fryers for residents, many of whom were reported as having safety issues with stove-top cooking.

One-on-one resident support provided by CHWs in resident SROs was fully implemented by the second quarter. A total of 294 separate individual-level resident interventions were conducted by the end of the 1-year pilot with 140 PSH residents. The most frequent type of activity completed by the CHWs (n = 228 sessions) included pantry inspections for food insecurity/nutritional deficiency in resident SROs and/or follow-up on referrals received from PSH staff to intervene with individual residents experiencing food insecurity. In their SROs, CHWs engaged food insecure PSH residents in meal planning, label reading, and delivery of healthy foods through (1) the distribution of 176 large boxes of food (fresh vegetables and nonperishable items from the bi-weekly distribution provided by the regional food bank); (2) linkage to food pantries (both through the distribution of flyers with directions and/or accompanying residents to pick up food; (3) assisting residents with SNAP benefits in signing up for Amazon Fresh deliveries since there was not a close-by grocery store; and (4) providing residents with necessary kitchen items so they could cook and eat healthy food in their SROs (pots/pans, dishes, utensils/flatware, and small cooking appliances).

The second most common individual-level activity provided by CHWs was social services assistance that included assisting residents with SNAP/WIC applications and linkage to primary care (n = 19 sessions). Some residents were distrustful of existing co-located social services staff and formed bonds with the nutrition-focused CHWs who were able to assist residents in obtaining needed benefits to close the SNAP coverage gap. CHWs provided wellness checks and emergency food assistance for eight residents who were not leaving their SROs and were believed to not have food.

One-on-one nutrition education provided by the public health dietitian was provided in SROs for five residents. Three residents received one-on-one cooking supervision and food safety training in their SROs provided by CHWs. One-on-one CHW support was also provided for a resident with social anxiety during a trip to the grocery store and for a non-English-speaking resident with very low food security who was connected with culturally affirming healthy food items. Other resident support provided by CHWs included transportation to medical appointments (six sessions total) for two aging and disabled residents with chronic illnesses, including one resident who had advanced cancer.

3.5. Group-Level CHW Intervention

Ten nutrition education sessions were implemented by the public health dietitian during the third quarter of the project. As part of the planning process, the dietitian met with the CHWs weekly to plan nutrition education sessions that addressed the nutrition-based questions from the PSH residents. In particular, the residents asked for information on preparing meals to support the management of diabetes and heart disease and weight loss, having a balanced diet using meat-alternatives, and the importance of purchasing organic foods. In addition to addressing resident questions, session topics planned by the dietitian included nutrition-label reading, food safety (cooking temperatures/use of thermometers, storing food, defrosting meat, and the meaning of sell-by dates), and knife skills. The CHWs and dietitian also engaged the residents in playing a series of weekly nutrition games that the dietitian developed for this project including The Price is Right; MyPlate Nutrition Bingo; Nutrition Crossword Puzzles; Nutrition Pictionary; and Nutrition Jeopardy. The nutrition games were very popular among the residents, and multiple comments were obtained on the new knowledge they had gained to improve healthy eating. In particular, residents reported learning how to purchase and prepare healthier food such as low-salt canned goods, corn tortillas, natural peanut butter, and Greek yogurt. One resident commented “I enjoyed the nutrition sessions the most… I was homeless for two years and needed to be reminded of the basics again like how to slice avocados and tomatoes… practicing during the nutrition classes was helpful”. Several residents also commented on the positive experiences they were having in a group activity with other residents. Two interviewees reported learning to spell and pronounce vegetables correctly. When asked what nutrition program activities he enjoyed, one resident described the nutrition games as “a lot of enthusiasm around it—I learned how to spell squash, turnips, collard greens—different vegetables… fruit juices… was a lot of fun as well… loved the program… loved the games—the program was very good”. During a nutrition game, a resident responded enthusiastically “You can add yogurt to chili? I didn’t know that!” Another resident reported “I am using a lot of vegetables and fruits now… I cook apple soup and cook vegetables for my noodles”. Another interviewee reported that the games helped him to “learn about the different fruits and vegetables and the right amount of salt”. A resident reported that his favorite activity was the nutrition games because “during the nutrition games… instead of everybody hating on each other, we came together as one as we should be… enjoyed all that”. Another interviewee described how he met other residents through the nutrition games reporting “I was in the hospital… I have kidney and liver problems… I met some good and courteous people [during the nutrition games]… I am from Louisiana and I know how to cook… but I learned about healthy seasoning”. Another resident reported that she benefited from learning “price points and nutritional information about the food”. A resident with diabetes reported that during the nutrition games “I won… was pretty good in the games… I am a diabetic and knew stuff from diabetic classes and won games… knew the answers from Dawn Center [Diabetes Awareness and Wellness Network—diabetes self-management education program in the region]… I graduated… they [DAWN] teach you all the things you need to know—about grains and fibers—when they [dietitian and CHWs with the project] were asking questions I was popping up—I got ahead of a whole lot of people”.

Twenty healthy cooking classes were conducted from the second through to the fourth quarters, and class participation ranged from 2 to 16 participants, with a mean number of participants 7 per class (138 participants total). The kitchen equipment utilized in the cooking class was modeled after the kitchens in resident SROs (two burner stoves and a microwave oven), and the residents participated in a community meal after each class. Food items including fresh fruits and vegetables and pantry staples from the bi-weekly food distribution (donated by the regional food bank)) were used to teach residents how to cook healthy meals with foods they could access through the food bank. A major theme arising from the healthy cooking classes was related to expanded preferences for and attitudes towards healthy foods residents could easily prepare in their SROs. Resident feedback provided on comment cards after each class identified popular recipes including black bean soup, water infused with cucumbers, potato scramble, easy bean chili with fresh tomatoes and mustard greens, apple crisp in a mug using oatmeal packets from the food distribution to make the crispy topping, and omelets in a mug with eggs, green and red bell peppers, spinach, shredded Italian or cheddar cheese, milk, and salsa (if desired). During a weekly staff meeting, resident feedback was reviewed and a CHW reported that “the residents were initially put off and uninterested in cutting up and making their own omelets, but they came around to it later… many of them were also taken aback to cook the eggs in the microwave, rather than the stove, and were unsure how they would taste, however, all of the residents who made the eggs enjoyed it”.

Additional class favorites included yogurt parfaits with Greek yogurt, granola, raspberries, blueberries, and honey. One CHW reported during a planning meeting that “residents seem to really enjoy yogurt and being able to pick out the toppings”. After participating in the fruit and vegetable smoothie stations, some residents expressed wanting a blender to make their own smoothies in order to consume more fruits and vegetables. Feedback obtained following the healthy cooking class, taco stations, indicated residents enjoyed cutting their own vegetables and making spice blends, which were added to black beans. One resident reported that during a cooking class “I learned things about herbs I did not know”. A theme emerged from the analysis of the feedback on the comment cards that regaining food preparation practice skills lost during homelessness such as using knives to cut vegetables during cooking classes was a particularly important learning activity (mentioned by seven residents on comment cards). One resident reported that “learning about spices in the classes brought it back to me… how to cook… once you get it… taste buds help to create your own spice mix”. Another resident reported “All of it [cooking classes]… especially the black bean soup… I like to cook—to learn… I had forgotten a little… and I learned a whole lot… I really did need it… I am now cooking Spanish rice and beans and making salads”. An additional theme that emerged was that participating in the cooking classes exposed them to healthier food options that they began using when cooking on their SROs. One resident reported during a door-to-door distribution event “I did everything [in the cooking class]… cut the onions… used cold water… I prepped and cooked chili.. I learned to cook chili a different way… I put chopped onions in the air fryer I got from the program”.

Two grocery store pop-ups and six grocery store field trips were conducted by CHWs to engage residents in learning how to shop for healthy foods. Approximately 30 PSH residents attended each pop-up event to access donated foods. The number of PSH residents attending grocery store field trips ranged from three to six per trip (mean number of five participants per trip). Project team members met residents (who were transported via Lyft) at a grocery store (a 7 min and 3.2-mile drive from the PSH buildings), which most residents had not shopped at before due to transportation barriers. As part of the field trip, the dietitian and CHWs engaged participating residents in learning how to shop for healthy and affordable food items. During each field trip, participants were given donated gift cards to purchase an item from each food group. CHWs also purchased insulated bags for their groceries and glass containers to store leftovers in. A major theme that emerged related to the grocery store fields trip was related to community re-entry and learning to grocery shop for healthy foods as a group. One resident commented that “the best part of being here is being with my friends”. Another resident commented that she was not purchasing items yet and reported “I am walking around learning and taking notes about what is here”. Another resident was excited to learn about all the different spices that were available that could be used in place of salt as he reported having hypertension. Another resident reported benefitting from the two grocery store field trips he participated in reporting “I hadn’t ridden in a car in a long time… being able to go to the grocery store with others was helpful because this is not something I would do by myself”.

Three community meals were served during special occasions and were well attended including Thanksgiving, which had 16 PSH residents attending, the medical student luncheon with approximately 25 PSH residents attending along with medical students and project staff, the mental health wellness luncheon which had approximately 25 PSH residents attending, and the program graduation which had 28 PSH residents attending. One resident commented that “I enjoyed the community meals because I like to visit with others… and when I go to the grocery store, I always buy the same thing… during the lunches I tried a variety of food… it was good food”.

Four community gardening events were conducted that included 11 different PSH residents (3–4 participants per event). Prior to beginning the gardening component of the project, leadership toured a large farm run by one of the pastors at the faith-based community partner. Additionally, CHWs toured a university-based teaching garden run by the public health dietitian at the school of public health. CHWs obtained a small grant from a local native plants nursery, which was used to purchase seeds and herbs. Using grant funds and in-kind contribution from the school of public health, grow bags and soil were purchased for residents. Gardening activities included planting herbs in planters at one PSH building and planting herbs and vegetables in individual grow bags at the other PSH building. To encourage autonomy, each resident received their own grow bag and chose which vegetables/herbs to plant (lettuce, collard greens, kale, etc.). A major theme that emerged was resident ownership of maintenance of the community garden. One resident referred to the plants in her garden grow bag as “her babies” and formed a watering group with another resident to ensure the plants in the grow bags received enough water. Residents in the gardening group also identified times they could go to the garden together outside of the gardening classes, which helped to build community among the residents. Another resident reported during the key informant interviews that community gardening was one of his favorite program activities because “when you see it green and growing it makes me feel good”.